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Insurance - California Building Evaluation & Construction, Inc. - 2017-02-23 (2) CALIF23 OP ID: MC ACORO" CERTIFICATE OF LIABILITY INSURANCE DATE 02/16IDDIYYYY) `—� 02116!2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CNAME CT Miriam E.Rothey Hunter Insurance Services,Inc PHONE 888157639 FAX Agency Lic#OD94594 WC.No.Ext): - (AIC,No):619-465-1926 1950 Cordell Ct.Ste 101 ADDRESS:miriam@hunteronline.com EI Cajon CA 92020 Miriam E Rothey INSURER(S)AFFORDING COVERAGE NAIC i INSURER A:Associated Industries Ins.Co. 23140 INSURED California Building Evaluation INSURERB:National Union Fire Insurance 19445 Construction Inc INSURERC:State Compensation Ins.Fund 35076 2115 2115 W.Crescent Ave.Ste#225 Anaheim,CA 92801 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IH TYPE OF INSURANCE ADM SUBR POUCY EFF POUCY EXP LIMITS LTR INSD,WVD POLICY NUMBER (MMIDOIYYYY) (MMIDDIYYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR X X AES102644203 05/09/2016 05/09/2017 DAMAGE TG RENTED 100 000 PREMISES(Ea occurrence) $ , MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY .7 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) UMBRELLA LLkB _ OCCUR EACH OCCURRENCE $ 4,000,000 B X EXCESS LAB CLAIMS-MADE EBU061213901 04/13/2016 04/13/2017 AGGREGATE $ 4,000,000 DED RETENTION$ $ WORKERS COMPENSATION X PER 0TH- AND EMPLOYERS'LIABILITY STATUTE ER YlN C AFFICERANY PRIIETOR/PARTNER/7 E_XECUT1VE NrA 15119122016 05/01/2016 05/01/2017 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Costa Mesa Sanitary District, their elected and appointed officials, agents, officers, volunteers, and employees are named Additional Insured, per attached endorsement. Re: Various Locations CERTIFICATE HOLDER CANCELLATION COSTAME SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Costa Mesa Sanitary District ACCORDANCE WITH THE POLICY PROVISIONS. 290 Paularino Avenue Costa Mesa,CA 92626 AUTHORIZEDREPRESENTATIVE Co'1/1 1-7f& 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 1 IL 00 17 11 98 COMMON POLICY CONDITIONS i All Coverage Parts included in this policy are subject to the following conditions. A. Cancellation b. Give you reports on the conditions we find; 1. The first Named Insured shown in the Declara- and tions may cancel this policy by mailing or deli- c. Recommend changes. vering to us advance written notice of cancella- 2. We are not obligated to make any inspections, tion. surveys, reports or recommendations and any 2. We may cancel this policy by mailing or deliver- such actions we do undertake relate only to fin- ing to the first Named Insured written notice of surability and the premiums to be charged. We cancellation at least: do not make safety inspections. We do not un- a. 10 days before the effective date of cancel- dertake to perform the duty of any person or lation if we cancel for nonpayment of pre- organization to provide for the health or safety mium;or of workers or the public. And we do not warrant b. 30 days before the effective date of cancel that conditions: lation if we cancel for any other reason. a. Are safe or healthful;or 3. We will mail or deliver our notice to the first b. Comply with laws, regulations, codes or Named Insureds last mailing address known to standards. us. 3. Paragraphs 1. and 2. of this condition apply not 4. Notice of cancellation will state the effective only to us, but also to any rating, advisory, rate date of cancellation. The policy period will end service or similar organization which makes in- on that date. surance inspections, surveys, reports or rec- ommendations. 5. If this policy is cancelled, we will send the first Named Insured any premium refund due. If we 4. Paragraph 2. of this condition does not apply to cancel, the refund will be pro rata. If the first any inspections, surveys, reports or recom- Named Insured cancels, the refund may be mendations we may make relative to certifica- less than pro rata. The cancellation will be ef- tion, under state or municipal statutes, ordin- fective even if we have not made or offered a ances or regulations, of boilers, pressure ves- refund. sels or elevators. 6. If notice is mailed, proof of mailing will be suffi- E. Premiums cient proof of notice. The first Named Insured shown in the Declara- B. Changes tions: This policy contains all the agreements between 1. Is responsible for the payment of all premiums; you and us concerning the insurance afforded. and The first Named Insured shown in the Declarations 2. Will be the payee for any return premiums we is authorized to make changes in the terms of this pay. policy with our consent. This policy's terms can be F. Transfer Of Your Rights And Duties Under This amended or waived only by endorsement issued Policy I by us and made a part of this policy. Your rights and duties under this policy may not be C. Examination Of Your Books And Records transferred without our written consent except in We may examine and audit your books and the case of death of an individual named insured. records as they relate to this policy at any time dur If you die, your rights and duties will be transferred ing the policy period and up to three years after- to your legal representative but only while acting ward. within the scope of duties as your legal representa- D. Inspections And Surveys tive. Until your legal representative is appointed, 1. We have the right to: anyone having proper temporary custody of your property will have your rights and duties but only a. Make inspections and surveys at any time; with respect to that property. IL 00 1711 98 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 ❑ POLICY NUMBER:AES1026442 03 COMMERCIAL GENERAL LIABILITY CG 24040509 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: All persons or organizations where required by written contract with the Named Insured Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8.Transfer Of Rights Of Recovery Against Others To Us of Section IV—Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work"clone under a contract with that person or organization and included in the"products- completed operations hazard".This waiver applies only to the person or organization shown in the Schedule above. • CG 24 04 05 09 ®Insurance Services Office, Inc., 2008 Page 1 of 1 0 POLICY NUMBER:AES1026442 03 COMMERCIAL GENERAL LIABILITY NX GL 009 08 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON-CONTRIBUTING INSURANCE (THIRD-PARTY) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Third Party: All persons or organizations where required by written contract with the Named Insured (Absence of a specifically named Third Party above means that the provisions of this endorsement apply as required by written contractual agreement with any Third Party for whom you are performing work.) Paragraph 4.of SECTION IV:COMMERCIAL GENERAL LIABILITY CONDITIONS is replaced by the following: 4. Other Insurance: With respect to the Third Party shown above, this insurance is primary and non-contributing. Any and all other valid and collectable insurance available to such Third Party in respect of work performed by you under written contractual agreements with said Third Party for loss covered by this policy, shall in no instance be considered as primary, co-insurance, or contributing insurance. Rather, any such other insurance shall be considered excess over and above the insurance provided by this policy. NX GL 009 08 09 Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc.,with its permission POLICY NUMBER: AES1026442 03 COMMERCIAL GENERAL LIABILITY CG 20370704 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Operations All persons or organizations where written contract with the Named Insured requires additional insured completed operations coverage. This form does not apply to your work on"residential property". Information required to complete this Schedule, if not shown above,will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for"bodily injury"or"property dam- age" caused, in whole or in part, by 'your work' at the location designated and described in the sche- dule of this endorsement performed for that addi- tional insured and included in the "products- completed operations hazard". • CG 20 37 07 04 ©ISO Properties, Inc., 2004 Page 1 of 1 0 IIS COMMERCIAL GENERAL LIABILITY CG 20 33 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured any person or or- additional insureds, the following additional exclu- ganization for whom you are performing operations sions apply: when you and such person or organization have This insurance does not apply to: agreed in writing in a contract or agreement that such person or organization be added as an addi- 1. "Bodily injury", "property damage" or "personal tio nal insured on your policy. Such person or or- and advertising injury"arising out of the render- ganization is an additional insured only with re- ing of, or the failure to render, any professional spect to liability for "bodily injury", "property architectural, engineering or surveying servic- damage" or "personal and advertising injury" es, including: caused, in whole or in part, by: a. The preparing, approving, or failing to pre- 1. Your acts or omissions; or pare or approve, maps, shop drawings, opi- nions, reports, surveys, field orders, change 2. The acts or omissions of those acting on your orders or drawings and specifications; or behalf; in the performance of your ongoing operations for b. Supervisory, inspection, architectural or the additional insured. engineering activities. 2. "Bodily injury' or "property damage" occurring A person's or organization's status as an additional after: insured under this endorsement ends when your operations for that additional insured are corn- a. All work, including materials, parts or pleted. equipment furnished in connection with such work, on the project (other than ser- vice, maintenance or repairs) to be per- formed by or on behalf of the additional in- sured(s) at the location of the covered operations has been completed; or b. That portion of'your work"out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontrac- tor engaged in performing operations for a principal as a part of the same project. CG 20 33 07 04 ©ISO Properties, Inc., 2004 Page 1 of 1 ❑ CUSTOMER NUMBER: 829144 RUN DATE: 02-14-17 HELEN PANGELINAN INSURANCE AGENCY 12623 IMPERIAL HIGHWAY 207 SANTA FE SPRINGS, CA 90670 CALIFORNIA BUILDING 2115 W CRESCENT AVE ANAHEIM, CA 92801-3809 1 Insured Full Copy Policy Number 648273436 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMON POLICY CHANGE ENDORSEMENT Endorsement No. 006 Allstate Insurance Company Named Insured CALIFORNIA BUILDING Effective Date: 02-14-17 12:01 A.M., Standard Time Agent Name HELEN PANGELINAN INSURANCE AGENCY This endorsement will not be used to decrease coverages, increase rates or deductibles or alter any terms or conditions of coverage unless at the sole request of the insured. COVERAGE PART INFORMATION—Coverage parts affected by this change as indicated by x❑below. n Commercial Property n Commercial General Liability n Commercial Crime nC• ommercial Inland Marine I ( C• OMMERCIAL AUTOMOBILE NO CHARGE The following item(s): Insured's Name Insured's Mailing Address nPolicy Number Company Effective/Expiration Date Insured's Legal Status/Business of Insured nPayment Plan n Premium Determination Additional Interested Parties Coverage Forms and Endorsements Limits/Exposures Deductibles Covered Property/Location Description Classification/Class Codes Rates Underlying Exposure/Insurance is(are) changed to read (See Additional Page(s)} THE FOLLOWING ADDITIONAL INTEREST (ADDITIONAL INSURED - OTHER) HAS BEEN ADDED TO THE POLICY: COSTA MESA SANITARY DISTRICT 290 PAULARINO AVE COSTA MESA CA 92626-3314 The above amendments result in a change in the premium as follows: This premium does not include taxes and surcharges. X No Changes To be Adjusted at Audit Additional NO CHARGE Return NO CHARGE Tax and Surcharge Changes Additional Return Countersigned By: HELEN PANGELINAN INSURANCE AGENCY AUTHORIZED AGENT DM CW 30 01 10 Allstate Insurance Company Insured Full Copy Policy Number 648273436 COMMON POLICY CHANGE ENDORSEMENT Endorsement No. 006 Allstate Insurance Company Named Insured CALIFORNIA BUILDING Effective Date: 02-14-17 12:01 A.M., Standard Time Agent Name HELEN PANGELINAN INSURANCE AGENCY POLICY CHANGES ENDORSEMENT DESCRIPTION (CONT'D) ALL OTHER TERMS AND CONDITIONS REMAIN THE SAME REMOVAL PERMIT If this policy includes the Commercial Property Coverage Part, the following applies with respect to the Coverage Part: If Covered Property is removed to a new location that is described on this Policy Change, you may extend this insurance to include that Covered Property at each location during the removal. Coverage at each location will apply in the proportion that the value at each location bears to the value of all Covered Property being removed. This permit applies up to 10 days after the effective date of this Policy Change; after that, this insurance does not apply at the previous location. DM CW 30 01 10 Allstate Insurance Company Insured Full Copy -. DM CW 12 01 10 Policy Number 648273436 SCHEDULE OF FORMS AND ENDORSEMENTS Allstate Insurance Company Named Insured CALIFORNIA BUILDING Effective Date: 02-14-17 12:01 A.M., Standard Time Agent Name HELEN PANGELINAN INSURANCE AGENCY • COMMON POLICY FORMS AND ENDORSEMENTS DM CW 30 01-10 COMMON POLICY CHANGE ENDORSEMENT DM CW 12 01-10 SCHEDULE OF FORMS AND ENDORSEMENTS AUTOMOBILE FORMS AND ENDORSEMENTS CA 20 48 10-13 DESIGNATED INSURED • • DM CW 12 01 10 Allstate Insurance Company Insured Full Copy CI CW A02 10 11 CERTIFICATE OF INSURANCE This certificate is issued for informational purposes only. It certifies that the policies listed in this document have been issued to the Named Insured. It does not grant any rights to any party nor can it be used, in any way, to modify coverage provided by such policies. Alteration of this certificate does not change the terms, exclusions or conditions of such policies. Coverage is subject to the provisions of the policies, including any exclusions or conditions, regard- less of the provisions of any other contract, such as between the certificate holder and the Named Insured. The limits shown below are the limits provided at the policy inception.Subsequent paid claims may reduce these limits. Certificate Holder. Named Insured: COSTA MESA SANITARY DISTRICT CALIFORNIA BUILDING 290 PAULARINO AVE 2115 W CRESCENT AVE COSTA MESA, CA 92626-3314 ANAHEIM CA 92801-3809 Automobile Liability Insurer Name: Allstate Insurance Company PolicyNumber. 648273436 1-Any Auto 2-Owned Autos Only 3-Owned Priv.Pass.Autos Only 4-Owned Autos Other Than Priv. 5-Owned Autos Subject to No 6-Owned Autos Subject to a Compulsory UM Law Pass.Autos Only Fault X 7-Specifically Described Autos X 8-Hired Autos Only X 9-Non-owned Autos Only Policy Effective Date: 02-26-2016 Policy Expiration Date: 02-26-2017 Limits Of $ 1,000,000 Combined Single Limit(each accident) Insurance: BI Per Person BI Per Accident PD Per Accident Description of Operations/Locations/Vehides/Endorsements/Spedal Provisions Interested Party Type: ADDITIONAL INSURED - OTHER THIS CERTIFICATE DOES NOT GRANT ANY COVERAGE OR RIGHTS TO THE CERTIFICATE HOLDER. IF THIS CERTIFICATE INDICATES THAT THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED, THE POLICY(IES) MUST EITHER BE ENDORSED OR CONTAIN SPECIFIC LANGUAGE PROVIDING THE CERTIFICATE HOLDER WITH ADDITIONAL INSURED STATUS.THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED ONLY TO THE EXTENT INDICATED IN SUCH POLICY LANGUAGE OR ENDORSEMENT. Producer. HELEN PANGELINAN INSURANCE AGENCY Authorized Representative: Date: 02-14-17 Includes copyrighted material of Insurance Services Office, Inc.,with its permission CI CW A02 10 11 Allstate Insurance Company Page 1 of 1 Insured Full Copy CI CW A02 10 11 CERTIFICATE OF INSURANCE This certificate is issued for informational purposes only. It certifies that the policies listed in this document have been issued to the Named Insured. It does not grant any rights to any party nor can it be used,in any way, to modify coverage provided by such policies.Alteration of this certificate does not change the terms,exclusions or conditions of such policies.Coverage is subject to the provisions of the policies, induding any exclusions or conditions, regardless of the provisions of any other contract, such as between the certificate holder and the Named Insured. The lints shown below are the limits provided at the policy inception. Subsequent paid claims may reduce these limits. Certificate Holder. Named Insured: COSTA MESA SANITARY DISTRICT CALIFORNIA BUILDING 290 PAULARINO AVE 2115 W CRESCENT AVE COSTA MESA, CA USA 926263314 ANAHEIM CA 92801-3809 Automobile Liability Insurer Name:Allstate Insurance Company Policy Number. 648273436 1-Any Auto 2-Owned Autos Only 3-Owned Priv.Pass.Autos Only 4-Owned Autos Other Than Priv. 5-Owned Autos Subject to 6-Owned Autos Subject to a Compulsory UM Law Pass.Autos Only No Fault X 7-Specifically Described Autos X 8-Hired Autos Only X ,9-Nonowned Autos Only Policy Effective Date: 02-26-2016 Policy Expiration Date: 02-26-2017 Umits of $1,000,000 Combined Single Limit(each accident) Insurance: BI Per Person BI Per Accident PD Per Accident Description of Operations/Locations/Vehides/Endorsements/Spedal Provisions Interested Party Type: Additional Insured - All Other THIS CERTIFICATE DOES NOT GRANT ANY COVERAGE OR RIGHTS TO THE CERTIFICATE HOLDER. IF THIS CERTIFICATE INDICATES THAT THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED, THE POLICY(IES)MUST EITHER BE ENDORSED OR CONTAIN SPECIFIC LANGUAGE PROVIDING THE CERTIFICATE HOLDER WITH ADDITIONAL INSURED STATUS. THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED ONLY TO THE EXTENT INDICATED IN SUCH POLICY LANGUAGE OR ENDORSEMENT. Producer. HELEN PANGELINAN INSURANCE AGENCY Authorized Representative: Date: 02-14-17 Includes copyrighted material of Insurance Services Office, Inc.,with its permission CI CW A02 10 11 Allstate Insurance Company Page 1 of 1 Insured Full Copy POLICY NUMBER: 648273436 COMMERCIAL AUTO CA 20 48 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s)who are"insureds"for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: CALIFORNIA BUILDING Endorsement Effective Date: 02-14-2017 SCHEDULE Name Of Person(s)Or Organization(s): COSTA MESA SANITARY DISTRICT 290 PAULARINO AVE COSTA MESA, CA USA 926263314 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an 'Insured"for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an 'Insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II— Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I — Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 481013 ©Insurance Services Office, Inc. 2011 Page 1 of 1 Insured Full Copy • k { CUSTOMER NUMBER: 829144 RUN DATE: 02-14-17 HELEN PANGELINAN INSURANCE AGENCY 12623 IMPERIAL HIGHWAY 207 SANTA FE SPRINGS, CA 90670 HELEN PANGELINAN INSURANCE AGENCY 12623 IMPERIAL HIGHWAY 207 SANTA FE SPRINGS, CA 90670 Agent Copy Policy Number 648273436 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMON POLICY CHANGE ENDORSEMENT Endorsement No. 006 Allstate Insurance Company Named Insured CALIFORNIA BUILDING Effective Date: 02-14-17 12:01 A.M., Standard Time Agent Name HELEN PANGELINAN INSURANCE AGENCY This endorsement will not be used to decrease coverages, increase rates or deductibles or alter any terms or conditions of coverage unless at the sole request of the insured. COVERAGE PART INFORMATION—Coverage parts affected by this change as indicated by below. n Commercial Property nCommercial General Liability n Commercial Crime n Commercial Inland Marine n COMMERCIAL AUTOMOBILE NO CHARGE n The following item(s): nInsured's Name Insured's Mailing Address nPolicy Number n Company FlEffective/Expiration Date n Insured's Legal Status/Business of Insured Payment Plan Premium Determination • nAdditional Interested Parties Coverage Forms and Endorsements nLimits/Exposures Deductibles nCovered Property/Location Description Classification/Class Codes nRates Underlying Exposure/Insurance is(are)changed to read (See Additional Page(s)} THE FOLLOWING ADDITIONAL INTEREST (ADDITIONAL INSURED - OTHER) HAS BEEN ADDED TO THE POLICY: COSTA MESA SANITARY DISTRICT 290 PAULARINO AVE COSTA MESA CA 92626-3314 The above amendments result in a change in the premium as follows: This premium does not indude taxes and surcharges. X No Changes To be Adjusted at Audit Additional NO CHARGE Return NO CHARGE • Tax and Surcharge Changes Additional Return Countersigned By: HELEN PANGELINAN INSURANCE AGENCY C AUTHORIZED AGENT DM CW 30 01 10 Allstate Insurance Company Agent Copy Policy Number 648273436 COMMON POLICY CHANGE ENDORSEMENT Endorsement No. 006 Allstate Insurance Company Named Insured CALIFORNIA BUILDING Effective Date: 02-14-17 12:01 A.M., Standard Time Agent Name HELEN PANGELINAN INSURANCE AGENCY POLICY CHANGES ENDORSEMENT DESCRIPTION (CONT'D) ALL OTHER TERMS AND CONDITIONS REMAIN THE SAME • • • • REMOVAL PERMIT If this policy includes the Commercial Property Coverage Part,the following applies with respect to the Coverage Part: If Covered Property is removed to a new location that is described on this Policy Change, you may extend this insurance to include that Covered Property at each location during the removal. Coverage at each location will apply in the proportion that the value at each location bears to the value of all Covered Property being removed. This permit applies up to 10 days after the effective date of this Policy Change; after that, this insurance does not apply at the previous location. DM CW 30 01 10 Allstate Insurance Company Agent Copy DM CW 12 01 10 Policy Number 648273436 SCHEDULE OF FORMS AND ENDORSEMENTS Allstate Insurance Company Named Insured CALIFORNIA BUILDING Effective Date: 02-14-17 12:01 A.M., Standard Time Agent Name HELEN PANGELINAN INSURANCE AGENCY COMMON POLICY FORMS AND ENDORSEMENTS DM CW 30 01-10 COMMON POLICY CHANGE ENDORSEMENT DM CW 12 01-10 SCHEDULE OF FORMS AND ENDORSEMENTS AUTOMOBILE FORMS AND ENDORSEMENTS CA 20 48 10-13 DESIGNATED INSURED • DM CW 12 01 10 Allstate Insurance Company /gent Copy • POLICY NUMBER: 648273436 COMMERCIAL AUTO CA2048 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are"insureds"for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: CALIFORNIA BUILDING Endorsement Effective Date: 02-14-2017 SCHEDULE Name Of Person(s)Or Organization(s): COSTA MESA SANITARY DISTRICT 290 PAULARINO AVE COSTA MESA, CA USA 926263314 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an Insured"for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an Insured" under the Who Is An Insured provision contained in Paragraph Al. of Section II — Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I — Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 481013 ©Insurance Services Office, Inc., 2011 Page 1 of 1 Agent Copy